Health & Safety Policy Statement

Version 2.0, 01 August 2014 ( Version 1.1, 14 January 2013 ) ( Version 1.0, 11 July 2012 )

Health & Safety Policy Statement The University of Southampton is committed to excellence in all our activities, and wants to change the world for the better through our research, teaching and enterprise activities and our staff and students’ contribution to society. The effective management of Health & Safety is an important element in our success. Good Health & Safety performance protects our staff, students, and others from harm. It supports all our activities by preventing disruption to our business, the loss of valuable assets, and harm to our reputation. It is also consistent with our commitment to social responsibility. We will achieve good Health & Safety performance by: 

Doing all that is reasonably practicable to prevent injury and work-related ill health.



A problem-solving, risk informed, and proportionate approach to Health & Safety.



Efficient operational and strategic planning for Health & Safety.



Positive engagement with staff and students on Health & Safety issues, to develop competence and gain commitment.



Seeking continual improvement in our Health & Safety management and performance.



Compliance with all applicable legal requirements for Health & Safety.



Using the good practice of the BS OHSAS 18001:2007 Health & Safety Management System.



Internal audit, and other monitoring as necessary, to measure progress, and to identify the corrective and preventive actions needed to maintain that progress.

04 April 2014

Responsibilities for Health & Safety Senior managers (Deans, Directors, Associate Deans, Deputy Directors, Heads of Academic Unit, Heads of Service) shall: 

Carry out the requirements below of all staff/PGRs, and managers, supervisors and leaders.



Ensure that there is conformity within their Faculty / Service / Academic Unit to the requirements of the University’s Health & Safety Management System.



Provide the necessary resources, infrastructure, processes, information and competent assistance in their Faculty / Service / Academic Unit to fulfil this Policy Statement.



Promote a positive Health & Safety culture in their Faculty / Service / Academic Unit, by proper consideration of Health & Safety issues, by participation and consultation with staff, and by demonstrable commitment and leadership.

Managers, supervisors and leaders (ie, those directing the activities of other staff/PGRs) shall: 

Carry out the requirements below of all staff/PGRs.



Ensure that there is a suitable and sufficient written risk assessment of all activities under their direction, and that the controls delineated therein are implemented.



Ensure that their staff/PGRs have training, information and supervision of the type, amount and quality necessary for safe working.



Ensure that all incidents (injuries, work-related ill-health, dangerous occurrences and ‘near-misses’) involving their staff/PGRs, or in areas they control, or in activities under their direction, are promptly reported.



Ensure that corrective and preventive actions identified by enforcing regulatory authorities for Health & Safety, audits, inspections, incident investigations, and/or staff/PGR consultation, are promptly and effectively implemented.



Seek and act on competent professional advice on Health & Safety.



Set a good example to the staff they manage/lead in regard to Health & Safety.

The general Health & Safety risk assessment template can be found on the Safety & Occupational Health website: http://www.southampton.ac.uk/healthandsafety/

All staff (including postgraduate research students, and employees of other organisations and visitors working in University facilities and premises) shall: 

Take reasonable care of themselves and others.



Cooperate with the University in the implementation of this Policy Statement.



Work in accordance with the controls delineated by risk assessments, and with any training and instruction given, and comply with all applicable local rules and arrangements.



Promptly report all incidents (injuries, work-related ill-health, dangerous occurrences and ‘near-misses’), and any perceived shortcomings in Health & Safety arrangements, and also decline to participate in activities they reasonably believe to be dangerous.

Incidents and near-misses must be promptly reported via the online report form on the Safety & Occupational Health website: http://www.southampton.ac.uk/healthandsafety/

All taught students (undergraduate and postgraduate) shall: 

Take reasonable care of themselves and others.



Cooperate with the University in the implementation of this Policy Statement.



Work in accordance with any training and instruction given by supervising staff, and comply with all applicable local rules and arrangements.



Promptly report to their supervisor or another member of staff any incidents (injuries, work-related ill-health, dangerous occurrences and ‘near-misses’), and any perceived shortcomings in Health & Safety arrangements, and also decline to participate in activities they reasonably believe to be dangerous.

The Safety & Occupational Health service (SOH) shall: 

Develop, implement, monitor and review this Policy Statement, including the Management System.



Provide professional Health & Safety guidance and support.



Develop and deliver an internal Health & Safety audit programme.



Develop and provide an incident reporting and investigation process.



Compile and sustain a Health & Safety risk and legal register.



Develop, implement, monitor and review a Health & Safety training programme.



Assist with emergency preparedness and response.



Provide and manage an occupational health service that gives timely, effective advice to managers and staff on health issues in relation to Health & Safety and employment matters.



Liaise with the enforcing regulatory authorities for Health & Safety.

SOH are at 26 University Road, can be contacted by phone on 23277 (02380 593277), by email at [email protected], and website: www.southampton.ac.uk/healthandsafety/. SOH operates Monday to Friday 0900-1700. In an emergency, contact University Central Control Room on 23311 (02380 593311). SOH is supplemented by Health & Safety Officers based within Faculties and Services. These Faculty & Service Health & Safety Officers report directly to their Deans and Directors on Health & Safety issues, and provide an important additional source of Health & Safety advice and facilitation embedded in Faculties and Services. Their remit is similar to SOH, but on a local basis. SOH and the Faculty/Service Health & Safety Officers work in close collaboration.

Governance of Health & Safety The Vice-Chancellor and University Council are ultimately accountable for Health & Safety at the University of Southampton. The Vice-Chancellor shares a collective responsibility for Health & Safety with the University Executive Group (UEG), comprising Provost, Pro-Vice-Chancellors, Deans, Chief Operating Officer and Registrar. The Deans, Chief Operating Officer and Registrar are then specifically responsible for Health & Safety within their Faculty and Services. Health & Safety responsibility then devolves as described in the Responsibilities section. The chart on the next page outlines the University’s arrangements for Health & Safety accountability, governance and reporting, according to the key below:

Executive / governing body Line of executive / governing accountability for Health & Safety Management control & monitoring body for Health & Safety Line of committee reporting for Health & Safety Consultative & representative body for Health & Safety

Professional advisory & support body for Health & Safety

Health & Safety management function

University of Southampton Health & Safety Accountability, Governance and Reporting

Version 1.0 22 July 2013

University Council

Vice-Chancellor University Executive Group

serious only

Faculty/Service Leadership Team

Chaired by Dean, Director or other senior manager, includes Faculty/ /Service Safety Officer, SOH liaison partner, and staff and Trade Union representatives

Faculty/Service Health & Safety Committee

serious only

Dean / Director

Deans, Chief Operating Officer and Registrar report annually to the Health & Safety Audit & Assurance Committee

Genetic Modification & Biological Safety Committee

Consultative Committee on Safety & Occupational Health

A member of the Faculty / Service H&S Committee (usually the Faculty / Service H&S Officer) represents the Faculty / Service on CCSOH

CCSOH is chaired by an Associate Dean or Head of AU, includes Head of Safety & OH, Deputy Directors of HR and Estates, staff representatives from all Faculties and Services, and Trade Union Safety Representatives

Health & Safety Audit & Assurance Committee

Safety & Occupational Health Committee

SOH reports to the COO, who leads on Health & Safety for UEG

SOH liaison partner

GMBSC is chaired by a relevant senior academic researcher, includes Biological Safety Adviser, and staff with appropriate expertise from all Faculties carrying out work with biological agents or GM

Biological Safety Adviser

Head of SOH summary only

SOHC is chaired by the Chief Operating Officer, includes Head of Safety & OH, two Deans, Directors of HR, Estates, and Student Services, and chairs of CCSOH and GMBSC

HSAAC is chaired by a member of Council, includes a Pro-ViceChancellor, and active senior Health & Safety professionals from a range of outside organisations, and attended by Chief Operating Officer and Head of Safety & OH

Chief Operating Officer

Head and Deputy Head of SOH

Safety & Occupational Health Service Corporate service of professional Health & Safety Advisers leading policy, system and process development, training, audit, and expert guidance and support

summary only

managers, supervisors, research and teaching programme leaders

workplace inspections

incident investigations

internal risk & compliance audits

internal management system audits

assurance reports

Health & Safety Management System Derived from BS OHSAS 18001:2007

1

Health & safety arrangements must be in accordance with the University Health & Safety Policy Statement

BS OHSAS 18001:2007 Clause 4.2



The Health & Safety Policy Statement has authority from the Vice-Chancellor and University Council, and provides a framework for management of Health & Safety for the University, its vision for Health & Safety, and also delineates the responsibilities and organisation of Health & Safety.



All Health & safety measures must be compatible with and in harmony with this Policy Statement.



Faculties / Services are not required to have their own local Health & Safety Policy statement, but if they elect to do so, then their statement must be consistent with the University Health & Safety Policy statement.



Faculties / Services must produce documented arrangements for the management of Health & Safety within their areas, which must carry the clear authority of the Dean / Director.

2(1)      

Work task and activities must have a suitable and sufficient written risk assessment

BS OHSAS 18001:2007 Clause 4.3.1

Risk assessment is critical for good Health & Safety performance, and an essential legal requirement. Risk assessment is almost always based around the task / activity, rather than around individuals, locations, chemicals or equipment, which should be considered as part of the overall task / activity risk assessment. There is no need to assess the obvious trivial risks of everyday life. Risk assessment must identify reasonably foreseeable hazards, estimate inherent (without controls) risk, and devise controls so that residual (with controls) risk is low so far as is reasonably practicable. Risk is reasonably foreseeable worst case consequence and likelihood of hazard event combined, estimated using the attached matrix. It is not necessary to consider far-fetched, improbable consequences (only the ‘reasonably foreseeable’).

2(2)

Risk assessments must identify all reasonably foreseeable hazards

BS OHSAS 18001:2007 Clause 4.3.1



Hazards are anything with potential to cause harm.



Harm could be physical injury or ill-health, but also damage to assets, loss of business continuity, etc.



All reasonably foreseeable hazards must be identified, not just the immediate, obvious or subject-specific.



It is not necessary to be concerned with far-fetched improbable hazards (only ‘reasonably foreseeable’).

2(3)

Risk assessments must produce effective, proportionate controls to reduce risk

BS OHSAS 18001:2007 Clause 4.3.1



Controls must eliminate risk where it is reasonably practicable to do so, or else reduce it to a level of low residual risk so far as is reasonably practicable, or else at least reduce it to a tolerable level of medium risk.



Controls can be substitution of the hazardous by the less hazardous, engineering controls, safe systems of work, training, instruction, information and supervision, or personal protective equipment (PPE).



An operating procedure is not in itself a risk assessment.



Risk assessment of some hazards have additional specific technical and legal requirements – for example, hazardous chemicals, biological agents, genetically modified organisms, ionising radiations, noise, etc.

2(4)

Controls specified in risk assessments must adhere to the hierarchy of risk control

BS OHSAS 18001:2007 Clause 4.3.1



Controls must be in the following legally required hierarchy, from most preferable to least: avoid hazard; substitute the hazardous with the less hazardous; apply engineering controls; apply a safe system of work; use personal protective equipment (PPE) as a ‘last resort’.



Where use of PPE is unavoidable, it must be correctly specified in the risk assessment, be fitted as necessary, be correctly used, stored and maintained (as per the risk assessment), be compatible with the task and other equipment, be ‘CE’ marked (ie, compliant with EU Regulations), and conform to relevant EU Standards (EN).

2(5)

Risk assessments for individuals must be produced when required

BS OHSAS 18001:2007 Clause 4.3.1



IT equipment (‘display screen equipment’ or DSE) produces significant musculoskeletal health risk. Each user (DSE used for more than an hour a day) must have an individual risk assessment covering their workstation and working posture and habits. This is a legal requirement.



A number of hazards pose increased risk for new & expectant mothers. Each new & expectant mother must have, as soon as is practicable, an individual risk assessment covering such hazards. This is a legal requirement.



Other risk assessments for individuals should be produced as necessary, such as for young persons (those less than 18 years of age), for disabled persons, etc.

2(6)

Risk assessments must, where appropriate, define safe and proper methods for disposal of waste

BS OHSAS 18001:2007 Clause 4.3.1



Wastes hazardous to human health and/or to the environment are subject to stringent statutory requirements, and must be managed accordingly, and this should form part of the risk assessment.



The duty of care does not end when an activity is finished and waste disposed. The relevant University policies and procedures on environment and waste management and compliance must be applied.

2(7)

Risk assessments must be reviewed

BS OHSAS 18001:2007 Clause 4.3.1



Risk assessments must be reviewed periodically, at least every two years, or sooner if inherent risk is high.



Risk assessments must also be reviewed after incidents, after changes to the task / activity, if staff / PGRs raise concerns, if there is a relevant change to the law or other relevant standards, or if there is anything else to suggest the assessment is not suitable and sufficient.



There must be a process to ensure effective review of risk assessments, and recording of those reviews.

2(8)

A risk register must be compiled

BS OHSAS 18001:2007 Clause 4.3.1



It is important to compile an overall register of major risks, outlining how those risks are either eliminated where reasonably practicable, or else reduced to a level of low residual risk so far as is reasonably practicable, or at least reduced to a tolerable level of medium risk, to provide assurance that such risks are recognised and controlled.



The risk register must be both ‘global’ across the University, and ‘local’ within Faculties and Services.



There must be a process to biannually update the register with new or altered risks.

3

Applicable legal requirements must be identified and complied with

BS OHSAS 18001:2007 Clause 4.3.2



Many of the requirements of this management system are also legal requirements. There may be other legal requirements depending on the work being done.



A register of legal requirements must be compiled, and compliance demonstrated, both ‘globally’ across the University, and ‘locally’ within Faculties and Services.



There must be a process to biannually update the register with changes to Health & Safety legislation.



There must be substantive, demonstrable compliance with all applicable Health & Safety legislation.

4

A substantive SMART action plan for Health & Safety must be developed, implemented and monitored

BS OHSAS 18001:2007 Clause 4.3.3



Effective planning is essential for Health & Safety management and performance.



The plan must be SMART (Specific, Measurable, Achievable, Responsibility-assigned, Time-scaled).



The plan must also be annual, comprehensive, informed by risk, and regularly and actively monitored for progress by managers, and by staff representatives via the Faculty / Service Health & Safety Committee.



The plan must include strategic management actions, and also any corrective and preventive actions arising from enforcing authority interventions, external and internal audits, routine inspections, emergency preparedness exercises, incident investigations, and Health & Safety Committee meetings.

5

Managers, supervisors and leaders (those directing activities of others) must take responsibility for Health & Safety



Managers, supervisors and leaders are accountable for the Health & Safety of their staff/PGRs, in law and in University Policy, and must:



Ensure risk assessments are done and the findings implemented for the work they direct.



Ensure necessary training of their staff/PGRs and themselves is done and effective.



Ensure incidents in their areas are reported and investigated.



Give timely and effective response to any corrective actions affecting their work and areas.



Allocate necessary resources (time and money) for Health & Safety.



Demonstrably lead by example in regard to Health & Safety.

6(1)

Training needs must be identified, and a training programme developed, delivered and recorded

BS OHSAS 18001:2007 Clause 4.4.1

BS OHSAS 18001:2007 Clause 4.4.2



Training is essential for good Health & Safety management and performance, is a legal requirement, and develops the knowledge and skills needed so staff are competent to work without undue risk.



For all staff / PGRs, the training necessary to work safely must be identified, including both training on Health & Safety management and arrangements, and specific technical training directly related to their work.



This identification of training needs must lead to a comprehensive Health & Safety training programme that is effectively communicated to all staff / PGRs and has demonstrable backing from senior managers.



Staff / PGRs must complete the training that is identified as required for them in this training programme, and their completion of that training must be recorded using a robust and readily accessible process, with those records retained for at least five years.

6(2)

Staff must complete University training on relevant aspects of Health & Safety management and arrangements



All new-start staff / PGRs must complete the University online Health & Safety induction training, and also a local induction within their Faculty / Service.



Managers, supervisors and leaders (those directing the activities of others) must complete the requisite University Health & Safety for Managers / Research Leaders training.



Staff / PGRs must complete the University Health & Safety risk assessment training.



Staff / PGRs who use IT workstations for more than an hour a day on average must complete the University online DSE training & assessment.



Staff / PGRs must also complete any other University Health & Safety training that is required for their work and its specific risks.

BS OHSAS 18001:2007 Clause 4.4.2

6(3)

Health & Safety training must be appropriate and effective

BS OHSAS 18001:2007 Clause 4.4.2



Health & Safety training should comprise both ‘global’ generic SOH-led University training on Health & Safety management and arrangements, and also ‘local’ specific Faculty / Service led training on aspects of Health & Safety relevant to work within the Faculty / Service, and SOH and Faculty / Service Health & Safety Officers must work in conjunction in the development and delivery of training.



Health & Safety training must have concise, relevant, clearly stated learning outcomes, and be assessed at time of delivery, to demonstrate, so far as is practicable, successful achievement of learning outcomes.



The on-going efficacy of training and its learning outcomes must be monitored.



The ‘lifespan’ of Health & Safety training, before further ‘refresher’ training is required, is no more than four years, unless a shorter period is stated in the learning outcomes or required by law.

7(1)

Competent person(s) must be appointed at University level to assist with achieving conformity to this system

BS OHSAS 18001:2007 Clause 4.4.2



The professional advisors in the University’s Safety & Occupational Health service (SOH) are ‘competent persons’ for Health & Safety ‘globally’ across the University, and must be qualified with NEBOSH Diploma (or equivalent in relation to specialist roles) as a minimum, and either have, or be actively working towards, chartered professional status (or equivalent in relation to specialist roles). SOH advisers must also be qualified as OHSAS 18001 Lead Auditors, and be qualified to the CIEH Level 3 Certificate in Education & Training, or equivalent.



SOH advisers liaise with relevant enforcing authorities (eg, HSE), act as Health & Safety auditors and trainers, lead investigations of serious incidents, provide expert advice and support, develop Health & Safety policy, systems, processes and training, and work in conjunction with Faculty / Service Health & Safety Officers.

7(2)

Competent person(s) must be appointed at Faculty / Service level to assist with achieving conformity to this system

BS OHSAS 18001:2007 Clause 4.4.2



Faculty / Service Health & Safety Officers (HSO) are ‘competent persons’ for Health & Safety ‘locally’ within each Faculty / Service. There must be a minimum of 1.0 FTE HSO in total for each Faculty and for Estates & Facilities, and a minimum of 0.5 FTE HSO in total for each of Student Services, iSolutions, Library and the remainder of Professional Services. No individual HSO should be less than 0.5 FTE on Health & Safety. Primary HSOs must be qualified with NEBOSH General Certificate as a minimum, and then further develop qualifications and skills with guidance and assistance from Head of Safety & Occupational Health.



HSOs facilitate and coordinate ‘local’ development and implementation of Health & Safety management and arrangements, but responsibility for Health & Safety remains with Deans, Directors and other managers. HSOs must refer serious incidents and any enforcing authority interactions or interventions to SOH.

8(1)

There must be effective communication on Health & Safety

BS OHSAS 18001:2007 Clause 4.4.3.1



Communication is important because it raises staff awareness of Health & Safety issues, and builds a positive culture towards Health & Safety.



Faculties/Services must ensure their staff are familiar with the University Health & Safety Policy Statement, their own documented local arrangements for Health & Safety, and any other Health & Safety information required to carry out their particular work activities safely and in compliance with applicable legislation.

8(2)   



There must be effective participation in and consultation on Health & Safety

BS OHSAS 18001:2007 Clause 4.4.3.2

Consultation is important because it builds sensible, workable and effective Health & Safety, and the engagement with staff wins their commitment. It is also a legal requirement. There must be demonstrable means for staff to review and feedback on proposed developments in Health & Safety arrangements, and to raise, and have addressed, Health & Safety concerns. In each Faculty / Service, there must be a Health & Safety committee, chaired by a senior manager, (Dean/Director, or one of their direct reports) that meets at least three times a year, and includes a reasonable cross-section of staff, with Trade Unions invited to appoint Safety Representatives. This committee should monitor progress on the Health & Safety plan, and may itself produce corrective and preventive actions. Relevant staff must be engaged in risk assessment, and appropriately involved in incident investigations.

9(1)

Necessary operational controls must be identified, documented and verified

BS OHSAS 18001:2007 Clause 4.4.6



‘Operational controls’ is a general term that includes controls from risk assessments, and other generic controls such as: housekeeping, lone work restrictions, preventative maintenance, contractor management, Local Exhaust Ventilation validation, verifying containment of hazardous agents, designation of areas, environmental monitoring and personal dosimetry for hazardous agents, PPE validation, immunisations, etc. NB This is not an exhaustive list.



Controls must be regularly verified as appropriate and effective, and records kept.

9(2)

Operational controls must include selection and control of contractors

BS OHSAS 18001:2007 Clause 4.4.6(c)



Contractors must meet the Health & Safety criteria (and also the insurance, security and environmental criteria) defined by the University, or otherwise not be used.



Contractors, when working on site, must be subject to the contractor control procedure of the University, unless subject to a full permit-to-work system or under the direct supervision and oversight of Estates & Facilities or their primary approved contractors. The control procedure must be applied to Estates & Facilities staff working in hazardous areas under the control of Faculties or other Services.



A full permit-to-work system must be applied for areas and work of high inherent risk.



Records must be kept of contractor selection, contractor control and permits-to-work.

10(1)

There must be effective emergency preparedness

BS OHSAS 18001:2007 Clause 4.4.7



Reasonably foreseeable emergencies must be identified, and reasonably practicable responses planned. This should be a part of risk assessment. It is not necessary to consider far-fetched, improbable events. Examples of emergencies include fire, flood, hazardous material spills / releases / exposures, etc.



Emergency roles (eg, fire wardens), training (eg, fire warden, lift evacuation, etc), exercises (eg, fire drills), and special equipment available (eg, for spill clean-up) must be provided as appropriate.



Personal emergency evacuation plans (‘PEEPs’) must be in place for all those who require one.



Clear, concise emergency information (‘grab packs’) for the emergency services must be prepared for each building.

10(2)

Emergency preparedness must include suitable and sufficient first aid cover

BS OHSAS 18001:2007 Clause 4.4.7



First Aid at Work qualified first-aiders in higher risk areas, and Emergency First Aid at Work qualified first-aiders in lower risk areas, must be provided at the HSE recommended ratio for high risk workplaces of 1 to 50 staff and PGRs, and be located according to staff/PGR distribution so far as is practicable.



Faculties / Services may elect to provide additional and/or specially trained first aid coverage for particular hazards and activities, such as fieldwork for example, and the relevant risk assessments should delineate this.



Local First aider contact lists must be readily available.

11

A programme of inspections must be developed and implemented

BS OHSAS 18001:2007 Clause 4.5.1/2



Inspections are critical examinations of the workplace, and are a vital part of Health & Safety management. They provide basic checking of legal compliance and conformity to this system and other relevant systems and standards, and vigilance for inadequately controlled risks or other undesirable situations. They should reinforce, share and promote good practice, and also provide an opportunity for staff to raise concerns.



Faculties / Services must develop and conduct an inspection programme. Outputs should be corrective and preventive actions, which are implemented and monitored via the Faculty / Service Health & Safety Plan.



Inspections can be organised by location, hazard, function, or any sensible mixture thereof. They must be clearly scoped according to risks, and based around a checklist framework or similar, tailored to the risk. In general, all areas should be inspected at least annually, and hazardous areas at least biannually.

12 





All incidents must be reported and investigated

Incidents include physical injury accidents, work-related illness, fires, dangerous occurrences, ‘near-misses’ (significant potential for injury, illness or fire, but harm did not occur). Incidents must be promptly reported to SOH, who will identify serious and RIDDOR (Reporting of Incidents, Diseases & Dangerous Occurrences Regulations) reportable incidents, make RIDDOR reports as required, and copy reports to HSOs. Incidents must be investigated, by HSOs for minor incidents, and by SOH in conjunction with HSOs for serious incidents. The reporting and investigation process should maintain proper confidentiality. OH also liaise with VC’s Office, Legal Services and Insurance Office re serious incidents. Investigations must be written, objective, evidential, constructive, identify immediate and underlying causes, and produce corrective and preventive actions, which are implemented and monitored via the Faculty / / Service Health & Safety Plan. Investigations should not seek to attribute blame.

13

Corrective and preventive actions must be identified and implemented



Corrective actions are those required to eliminate a legal non-compliance, a non-conformity to this system, an inadequately controlled risk, or other undesirable situation.



Preventive actions are the same except the issue is a potential one, rather than an actual one.



Corrective and preventive actions can be identified from risk assessments, consultation, inspections, audits, incident investigations and simple observation.



Corrective and preventive action must be recorded, implemented and monitored via Faculty / Service Health & Safety Plans and thence Faculty / Service Health & Safety Committees.

14(1) 



BS OHSAS 18001:2007 Clause 4.5.3.1

A programme of audits must be developed and implemented

BS OHSAS 18001:2007 Clause 4.5.3.2

BS OHSAS 18001:2007 Clause 4.5.5

Audits are a systematic, independent process for obtaining evidence and evaluating it objectively to determine extent to which audit criteria are fulfilled (ISO 19011:2011). Audit evidence can be documents and records, interviews and admissible statements, and observations. Audit findings are recommendations to improve conformity to the audit criteria. Audits are conducted by advisers from SOH trained as lead OHSAS 18001:2007 auditors, with additional invited external auditors for the management system audits. Management system audits have this management system as audit criteria. Risk / compliance audits examine high inherent risks and/or particular legal requirements, with audit criteria from legislation, authoritative codes of practice and guidance, standards and best practice. Audits are usually scoped on a Faculty / Service basis, with frequency and scopes determined by agreement between University senior management and the Health & Safety Audit & Assurance Committee of University Council.

14(2)

Faculties / Services must cooperate with the audit process, and implement corrective actions to address audit findings

BS OHSAS 18001:2007 Clause 4.5.5



Faculties / Services must cooperate with audits, providing the necessary evidence, personnel and facilities.



After each audit, Faculties / Services must promptly produce and implement an audit response action plan that delineates the specific, achievable, measurable, responsibility-assigned and time-scaled corrective and preventive actions necessary to resolve the non-conformities identified.



Faculties / Services must complete the corrective and preventive actions arising from audit findings.



For each Faculty / Service, audit findings, audit response action plans, and monitoring by SOH advisers of the implementation of the plans and corrective and preventive actions therein, is regularly presented to the University Health & Safety governance mechanism.

Health & safety risk estimation matrix High risk – requires controls to reduce risk before activity / task can commence (or continue). Medium risk – requires controls to reduce risk as much and as soon as is reasonably practicable. Low risk – all risk should be reduced to this tolerable level, so far as is reasonably practicable. Reasonably foreseeable worst case consequence Likelihood 3 of hazard event Likely high probability, 1 in 10 chance or higher, once in two weeks or longer for activities on a daily basis

Possible significant probability, 1 in 100 chance or higher, once in six months or longer for activities on a daily basis

Unlikely low probability, 1 in 1,000 chance or higher, once in four years or longer for activities on a daily basis

Rare very low probability, 1 in 10,000 chance or higher, once in a decade or longer for activities on a daily basis

Almost never extremely low probability, less than 1 in 100,000 chance, once in a century or longer for activities on a daily basis

Minor

Moderate

Major

Critical

Catastrophic fatal injury or illness for multiple persons

superficial injury;

significant injury or illness ;

serious injury or illness ;

fatal injury or illness;

or slight and temporary health effect

or temporary minor disability x

or significant or permanent disability

or substantial and permanent disability

medium risk

high risk

high risk

high risk

high risk

low risk

medium risk

high risk

high risk

high risk

low risk

low risk

medium risk

high risk

high risk

low risk

low risk

low risk

medium risk

high risk

low risk

low risk

low risk

low risk

medium risk

1

2

x

‘Significant injury’ could include, for example, laceration, burn, concussion, serious sprain, minor fracture, etc. ‘Significant illness’ could include, for example, dermatitis, minor work-related musculoskeletal conditions, partial hearing loss, etc. 1

‘Serious injury’ could include fracture or dislocation (other than digits), amputation, loss of sight, penetration or burn to eye, electric shock, asphyxia, or any injury leading to unconsciousness or requiring resuscitation or admittance to hospital for more than twenty-four hours. ‘Serious illness’ could include, for example, requiring medical treatment after chemical, biological or radiological exposure, severe debilitating musculoskeletal conditions, severe dermatitis, asthma, etc. 2

3

For likelihoods in between the listed values, use the higher likelihood to estimate risk. These probability definitions are only a guide.